Resident Student Medical Authorization

PURPOSE: Toauthorize emergency and/or non-emergency medical evaluation and treatment of resident students in the ENCORE Chamber Music Program at Gilmour Academy. Every effort will be made to contact a parent/legal guardian regarding medical care. Students who will be 18 or older as of June 11, 2017 may sign in lieu of a parent/legal guardian.

Student name *

Student name

First Name

Last Name

EMERGENCY CONTACT #1

EMERGENCY CONTACT #1

First Name

Last Name

Contact #1 relationship to student:

Contact #1 cell phone:

Contact #1 cell phone:

Country

(###)

###

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Contact #1 work phone:

Contact #1 work phone:

Country

(###)

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Contact #1 email address:

Additional contact #1 info:

Please list any other information you wish about this emergency contact here.

EMERGENCY CONTACT #2

EMERGENCY CONTACT #2

First Name

Last Name

Contact #2 relationship to student:

Contact #2 cell phone:

Contact #2 cell phone:

(###)

###

####

Contact #2 work phone:

Contact #2 work phone:

(###)

###

####

Contact #2 email address:

Additional contact #2 info:

Please list any other information you wish about this emergency contact here.

Insurance carrier *

Policy #: *

Group ID #: *

Policy holder (name on card): *

Policy holder (name on card):

First Name

Last Name

Policy holder D.O.B:

Policy holder D.O.B:

MM

DD

YYYY

Policy holder S.S.N.:

Student S.S.N.:

Signature of parent/legal guardian: *

By signing you are stating that the above insurance information is correct.

Today's date: *

Today's date:

MM

DD

YYYY

Current medication being taken by student:

Name of medication, dosage & reason

Allergies (food, medication, other information):

Disabilities:

Other physical activity restrictions:

Recent illness/injury/surgery:

Other medical information (please indicate if student carries an epipen or uses an inhaler):

To Grant Consent for medical treatment - signature of student (over 18 as of June 11, 2017) or parent/guardian required for resident student enrollment: *

Unless a Cleveland-based physician is designated, all care will be provided by local primary care providers.

Liability Release

PURPOSE: This document is provided in place of and to accommodate me, the parent/legal guardian of my Child, and to replace individual authorization for each ENCORE-sponsored activity. ENCORE-sponsored activities include but are not limited to all off-campus field trips and on-campus activities. For off-campus field trips, students will be driven by drivers provided by Gilmour Academy. On-campus activities may include sports and recreational activities, such as swimming, basketball and softball.

Students who will be 18 or older as of June 11, 2017 may sign for themselves in lieu of a parent/legal guardian.

I state that my child is a student in the ENCORE Chamber Music Institute summer program, housed at Gilmour Academy, an Ohio Not-for-Profit Corporation located at 34001 Cedar Road, Gates Mills, Ohio 44040, and that in consideration of the Agreement by ENCORE to permit my Child to participate in any and all ENCORE-sponsored activities, so state that:

1. I am aware of the nature of ENCORE-sponsored activities and understand there are risks/dangers attendant to my Child’s participation;

2. I hereby agree to permit my Child to participate in any and all such ENCORE-sponsored activities unless I advise ENCORE in writing beforehand that I revoke my permission for a particular activity or activities;

3. I warrant that I maintain accident and health insurance coverage for my Child that will cover my Child while he or she is attending ENCORE and while he or she is participating in any such ENCORE-sponsored activities;

4. In the event of a medical emergency, and after reasonable attempts have been unsuccessful to reach me, I hereby give permission for the representative of the ENCORE program and/or Gilmour Academy to arrange for/and/or authorize emergency medical treatment for my Child.

5. I agree to release, indemnify, protect, defend and hold harmless ENCORE and Gilmour Academy, and their respective teachers, administrators, trustees, directors, supervisors, agents, employees, faculty members, and all private persons or organizations volunteering services without charge (each, a “Protected Party”) to supervise or chaperone my Child while participating in the ENCORE-sponsored activities, from any claim or liability of whatsoever kind or nature, including but not limited to personal injury, including dismemberment and/or loss of life, or loss of any kind and/or property damage, court costs, attorneys’ fees and interest, as a result of my Child’ s participation in the ENCORE-sponsored activities. I do not agree, however, to such release in the case of willful or intentional inappropriate actions or inactions by employees of ENCORE or Gilmour Academy. Further, I hereby agree that no Protected Party shall be liable for any special, indirect or consequential damages to any party howsoever arising regardless of any negligence, including any damages that such Protected Party reasonably contemplated or should have anticipated;

6. I agree that ENCORE and Gilmour Academy, and their respective teachers, administrators, trustees, directors, supervisors, agents, employees, faculty members, and all private persons or organizations volunteering services without charge may terminate my Child’s participation in any ENCORE-sponsored activities if my Child fails to behave or act in accordance with ENCORE’s rules and/or regulations on conduct as set forth in the ENCORE Chamber Music Student Handbook 2017 and any other policy of Encore or Gilmour Academy, fails to follow the instructions and/or directions of teachers, faculty, administrators, trustees, supervisors, agents, employees and all private persons or organizations volunteering services, or evidence conduct deemed to be detrimental to or incompatible with the interest, comfort or welfare of those participating in the ENCORE-sponsored activities including students, ENCORE representatives and supervisors as determined by the representative of ENCORE in charge of the ENCORE-sponsored activity. Accordingly, I hereby authorize the Executive Director of ENCORE Chamber Music and other respective administrators including the residential hall supervisors to administer and enforce disciplinary action, without a refund of any tuition or expenses paid by me or my Child, in the event of any violation of or noncompliance with such rules and/or regulations by my Child.

7. I acknowledge that my Child will be required to bring his or her own instrument to ENCORE (other than pianists). I further acknowledge that either I or my Child is responsible for transporting his or her instrument to ENCORE's campus, at my own expense and risk of loss. I represent and warrant that I maintain an insurance policy that covers any damage to the instrument or theft of the instrument, and such insurance policy will remain in effect throughout the time my Child attends ENCORE. Without limiting the foregoing, I acknowledge and agree that neither ENCORE nor Gilmour Academy, nor their respective directors, employees, faculty or supervisors shall be liable for any damage to or theft of my Child’s instrument.

Signature of parent/guardian (or of student if over 18 as of June 11 2017): *

I acknowledge that I have read and agree to the terms set out above by ENCORE Chamber Music.

I am signing for:

I am signing for:

If you are a parent or guardian signing for your child, please write your child's name below.

First Name

Last Name

Today's Date *

Today's Date

MM

DD

YYYY

Thank you for signing the ENCORE 2017 liability release agreement!

Media Release

Use of Student's Image and Likeness Agreement

While at ENCORE, students may be filmed, videotaped or photographed during performances, practices, classes, off-campus events and other on-campus activities. ENCORE intends to use this media for future educational and promotional purposes as well as articles in the press. The media might be used for future promotional materials, such as postcards or brochures, ENCORE’s website, articles appearing in newspapers, magazines or online, or for class instruction.

By attending ENCORE Chamber Music and signing the media release, each student (or his or her parent) is agreeing to provide ENCORE Chamber Music with the exclusive ownership and right to use any photograph, video, recording or other media taken or recorded by ENCORE, Gilmour Academy, Cleveland Institute of Music or one of their representatives. Neither the student nor the parent will have the right to pre-approve any such use or receive royalties or other payments in exchange for such use. The student and/or parent waives any claim or right of ownership with respect to such media, including, without limitation, a claim of copyright infringement, the misappropriation of the student’s name and/or likeness, or any other similar claim relating to the use or ownership of such media.

Signature of parent/guardian (or of student if over 18 as over June 11 2017): *

I acknowledge that I have read and agree to the terms set out above by ENCORE Chamber Music.

I am signing for:

I am signing for:

If you are a parent or guardian signing for your child, please write your child's name below.

First Name

Last Name

Today's Date: *

Today's Date:

MM

DD

YYYY

Thank you for submitting the ENCORE 2017 media release agreement!

Roommate Request (Optional)

Student name *

Student name

First Name

Last Name

Name of requested roommate:

Name of requested roommate:

We will try our best to accommodate roommate requests; please note that submitting a request does not necessarily guarantee placement with your preferred roommate.

First Name

Last Name

ENCORE seeks to provide an inclusive experience for all of our students, and is committed to making the dormitories a safe space for students of all genders, ethnic backgrounds, or abilities. Any questions or concerns regarding dormitory policies can be addressed below, or brought to ENCORE administrators. If you or your child have any preferences or concerns regarding roommates or dorm rooms, please also list those specifications below.